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insulin Management in type 2 diabetes mellitus

PRACTICAL POINTERS FOR CLINICAL PRACTICE

What is so frightening about diabetes???

Denial, myths, fear....

I can’t have diabetes, I feel GREAATTTT!

Only fat people get diabetes, so if I keep my weight down, I won’t get it.

My grandmother told me that diabetes comes from eating too much sugar.

I took my medication once or twice a week. I really don’t think it helped, so I quit taking it.

the diabetes epidemic

MANAGE SMARTER AND MORE AGGRESSIVELY

Indications for Insulin therapy

Adjunctive therapy - used when oral agents alone fail to achieve target glycemic goals

Basal insulin at bedtime decrease fasting blood sugars, oral agents control blood sugar during the day.

Replacement therapy - used when both basal and meal-time insulin are needed.

Glucose Toxicity - use Intensive Insulin Therapy (IIT) for 2-4 weeks at diagnosis which may improve endogenous insulin secretion and sensitivity.

Triggers for starting insulin:

persistent glucose > 250 mg/dl.

HbA1c > 10%

ketonuria

symptoms - polyuria, polydipsia, weight loss

IIT used early can resolve glycemic issues faster than oral agents.

Other - during hospitalization, pre-operatively, with steroid therapy, or at any time that glycemic control deteriorates

triggers for starting insulin

HbA1c > 10%

Symptoms of polyuria, polydipsia, weight loss

Failure of multiple oral medications

Acute situations; e.g. infections, MI, stroke, trauma

Perioperative period

Pregnancy

Contraindications to oral medications

failure

Insulin Products

Insulin Regimens

How to Start and intensify INsulin

Starting insulin

Is a process

Generally takes a few weeks

Familiarize patient with insulin administration

Build patient confidence

Gradual improvement of glycemic control while avoiding hypoglycemic episodes

If available, consultation with CDE is invaluable

Start Simple

Long acting or immediate acting insulin

Add short acting with meals to reduce post-meal rises

Continue to use oral agents; Metformin, TZDs, DPP-4’s

Sulfonylureas - discontinue

May require 20-30% more insulin if oral agents are discontinued

Commercial for Certified Diabetes Educators

Insulin Regimens

Once daily injection of Glargine, Detemir, NPH

Given at bedtime to lower fasting blood glucose

Can be used alone or with oral agents

Detemir and NPH may need to be given twice daily

NPH associated with more hypoglycemia

Raising basal only can lead to lows at night

Glargine and Detemir are more costly than NPH

basal regimen

✰ Add short-acting insulin if post-meal blood sugars are high Split-Mix: consider that insulin proportions are typically 2/3 in morning and 1/3 in evening. Ratios of long-acting/NPH to rapid/Regular of 2:1 in am and 1:1 in evening. Split-mix often leads to hypoglycemia in middle of night related to NPH peak at 6-8 hours after dinner injection.

Intermediate and Short-Acting Regimen

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Basal-Bolus Regimen

Ideal for replacement insulin therapy

Preferred for patients who have unpredictable mealtime and activity schedules.Basal insulin is 40-50% of total daily dose of insulinBolus given pre-meal - should be 50-60% - may be adjusted according to carbohydrate counting using insulin-to-carbohydrate ratio

How to Figure Insulin to CArb Ratio (I:CR)

To Figure I:CR To Figure I:CR divide amount of divide amount of

carb person is carb person is consuming by consuming by

amount of insulin amount of insulin taken at meal taken at meal

Example: Example: 60gm ÷ 10 units = 660gm ÷ 10 units = 6

I:CR is 1:6I:CR is 1:6

If person If person eats 75 eats 75

gm carbsgm carbs

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75 mg ÷ 75 mg ÷ 6 =6 =

12 units12 units☞

Sensitivity/Correction Factor

Used for patients with varying blood glucose

Corrects pre-meal highs or lows

Given only before meals

Ensures that the post-meal glucose will be in acceptable range

More commonly used in Type1 vs. Type 2

Calculation: Sensitivity/Correction

FactorDivide 1500 by total daily dose (TDD) insulin - this determines the sensitivity ratio.

Example: 1500 ÷ 50 units/day = 30

Correction Factor: If patient blood sugar is 250 mg/dl. and target blood glucose range is 100 mg/dl. , figure 1 unit of insulin is needed for every 30 pts. above target range of 100 mg/dl.

Doing the Math

Target Glucose Range: 100 mg/dl.I:CR 1:6Sensitivity Factor: 1:30Patient blood glucose is: 250 mg/dl.

Calculation: SMBG Target 250 mg/dl. - 100mg/dl. = 150Sensitivity: 1:30 150÷30 = 5 unitsI:CR person eats 75 gms. at lunch = 12 unitsMeal Bolus =12 units PLUS 5 units correction = 17 units

In Intensive Insulin Therapy (IIT)

If person eats 3 meals/day and 3 carb snacks they should bolus 6

times per day

Better managed with consistent carb intake at meals rather than snacks - reduces # of injections to 3 per day

IIT IMPortant tips

OR teach patient about non-carb snacks

Self MOnitoring of Blood Glucose (SMBG)

Very important component of insulin management to assess and make appropriate and safe changes

Recommendations for testing vary as to patient and insulin type : 1-2 times if on basal regimen only OR 2-4 times for combined regimen.

REMEMBER: 4-8 testings provide only 4-8 “snapshots.” Can lose alot of information in between & at night

IMPORTANT: Evaluate fasting and 2 hour postprandial blood glucose readings when chosing basal insulin only, mixed insulins, or basal-bolus regimens (IIT)

Target is a blood sugar < 180 mg/dl. or A1c of 7% or less.

Need to check postprandials at different meals to identify a pattern that may be ocurring

CONTINUOUS GLUCOSE MONITORING (CGMS)

Medical Nutrition Therapy

Proper nutrition is essential to insulin management.

ADA recommends individualized MNT

Teaches carb counting and is individualized to patient’s level of understanding

Current Nutrition Current Nutrition Recommendations: Recommendations:

3 meals / day; 30-45 gms. carbs 3 meals / day; 30-45 gms. carbs eacheach

With or Without With or Without 1-2 snacks in between meals - if 1-2 snacks in between meals - if

each snack is < 30 gms. no each snack is < 30 gms. no additional additional

rapid-acting insulin neededrapid-acting insulin needed

Focus of MNT

Lifestyle changes

Increased physical activity

Pt. may chose to eat 3 meals/day OR small meals with snacks

CArbohydrates

Greatest impact on postprandial blood sugars

Patient should understand which foods contains carbs

Understand portion size & number of servings per meal/snack

Total carb consumption vs. type of carb impacts blood sugar control

No evidence to support low vs. high glycemic index diets

Artificial sweeteners are FDA approved for DM

Protein

Is widely misunderstood in diabetes glycemic control

Does raise plasma glucose concentration - amt. produced is small and does not appear in general blood circulation

Protein has not been found to slow carbohydrate absorption

Does not treat hypoglycemia

Adequate intake is important to euglycemia

FAts

Intake should be limited

Saturated fat is the primary determinant of LDL

Trans fats increase LDL & lower HDL - limit as much as possible

Initial MNT guidelines

Consume 3 meals/day, not skip meals

Meals no more than 4-6 hrs. apart

Set maximum carbohydrate intake per meal

Avoid regular soda, fruit juice, sport drinks, choose water

Food label - focus on serving size & total carbs

Men: 60-70 gms carbs., Women: 45-60 gms

Barriers to insulin

Hypoglycemia

Weight gain

Psychological Barriers

Lipodystrophy

Allergic reactions

Glargine insulin associated with cancer risk

IN Summary

Insulin is very effective but underused in T2DM☤

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Insulin can be used earlier in disease and as an adjunct to oral medications

Transition to insulin should not be regarded as a failure by patient or

providerPrimary care providers should be

familiar with indications for insulin, insulin regimens used & side effects Adequate support for patients is key

to transitioning and the success of treatment

"Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to

turn a life around."

~ Leo Buscaglia ~

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